• Tsegahun Manyazewal, Martha J Oosthuizen, and Mokgadi C Matlakala.
• Department of Health Studies, College of Human Science, University of South Africa, Pretoria, South Africa Ethiopian Public Health Association, Addis Ababa, Ethiopia.
• BMJ Open. 2016 Sep 20; 6 (9): e012582.

ObjectivesMany resource-limited countries have adopted and implemented healthcare reform to improve the quality of healthcare, but few have had much impact and strategies in support of these efforts remain limited. We aimed to explore and propose evidence-based strategies to strengthen implementation of healthcare reform in resource-limited settings.DesignDescriptive and exploratory designs in two phases. Phase I involved assessing the effectiveness of the healthcare reform implemented in Ethiopia in the form of business process reengineering, with evidence compiled from healthcare professionals through a self-administered questionnaire; and phase II involved proposing strategies and seeking consensus from experts using Delphi method.SettingPublic hospitals in central Ethiopia.Participants406 healthcare professionals and 10 senior health policy experts.FindingsThe healthcare reform that we evaluated was able to restructure hospital departments into case teams, with the goal of adopting a 'one-stop shopping' approach. However, shortages of critical infrastructure, furniture and supplies and job dissatisfaction continued to hamper the system. The most important predictors that influenced implementation of the reform were financial resources, top management commitment and support, collaborative working environment and information technology (IT). Five strategies with 14 operational objectives and 67 potential interventions that could strengthen the reform are proposed based on their strategic priority, which are as follows: reinforce patient-centred quality of care services; foster a healthy and respectful workforce environment; efficient and accountable leadership and governance; efficient use of hospital financing and maximise innovations and the use of health technologies.ConclusionsEffective implementation of healthcare reform remained a challenge for governments in resource-limited settings. Resilient operational, clinical and governance functions of health systems, as well as a motivated and committed health workforce, are important to move healthcare reform processes forward. Political commitments at this juncture might be critical though there need to be a clear demarcation between political and technical engagements.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

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